Original Medicare, Part A (hospital insurance) and Part B (medical insurance) does not provide prescription drug coverage except in the limited case of medications provided during an inpatient hospital stay. The Medicare Part D program offers Medicare beneficiaries the option of obtaining prescription drug coverage from private insurance companies that contract with Medicare. The availability of Medicare plans offering prescription drug coverage in Massachusetts may vary depending on where you live.
How Medicare Part D plans work in Massachusetts
In Massachusetts, as elsewhere in the United States, you may receive Medicare prescription drug coverage either from a stand-alone Medicare Part D Prescription Drug Plan or from a Medicare Advantage Prescription Drug plan available where you live. Whether you choose a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan depends upon the plans available where you live and your other choices in how you receive your Medicare benefits.
As a Massachusetts beneficiary, you may wish to sign up for a stand-alone Medicare Part D Prescription Drug Plan if your current Medicare coverage offers only health coverage. This is the case if you have Original Medicare Part A and/or Part B, or if you have Original Medicare Part A and Part B and a Medicare Supplement insurance plan, or a Medicare Advantage plan without prescription drug coverage.
Alternatively, you may choose to receive your Medicare hospital, medical and prescription drug coverage by enrolling in a Medicare Advantage Prescription Drug plan.
Eligibility and enrollment
The rules of eligibility vary some between stand-alone Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plan. To enroll in a stand-alone Medicare Prescription Drug Plan you must have Medicare Part A and/or Part B. You don’t necessarily need have both Part A and Part B, which may be your situation if, for example, you have other insurance through an employer-sponsored group health plan. To enroll in a Medicare Advantage Prescription Drug Plan, on the other hand, you must have both Part A and Part B because Medicare Advantage Prescription Drug plans are designed to be an alternative way for you to receive your Medicare Part A and Part B benefits, plus the prescription drug coverage of the Medicare Part D program. (Medicare Advantage plans may offer additional benefits not included in Original Medicare as well.) However, if you have end-stage renal disease (kidney failure) you typically are not eligible to enroll in a Medicare Advantage Prescription Drug plan because Original Medicare has provisions for coverage for treatment of this condition. You must live in the plan’s service area whether you choose to enroll in a stand-alone Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug plan.
The times you can enroll in a stand-alone Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug plan are similar in Massachusetts and throughout the United States.
You can enroll in a stand-alone Medicare Prescription Drug Plan during your Medicare Initial Enrollment Period. This seven-month period typically begins three months before the month you turn 65, includes your birthday month, and runs for three months after that month. If you’re collecting disability benefits from the Social Security Administration or the Railroad Retirement Board, your seven-month Initial Enrollment Period starts three months before your 25th month of collecting disability, includes that month, and continues for three months after that month (so it’s your 22nd through 28th month of getting disability benefits).
Medicare Advantage Prescription Drug plans have an enrollment period called the Initial Coverage Election Period. It’s usually the same time period as the Initial Enrollment Period described above, unless you delay enrollment in Medicare Part B.
You may sign up for a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan during the Annual Election Period (also called the Fall Open Enrollment Period), which runs from October 15 to December 7 each year. If you want to switch from one plan to another or return to Original Medicare, you may do so during the same period. However, if you delay enrollment in Medicare Part D, you might have to pay a late-enrollment penalty.
You can disenroll from Medicare Advantage and go back to Original Medicare, Part A and Part B, during the Medicare Advantage Open Enrollment Period, which runs annually from January 1 toMarch 31 . If you decide to return to Original Medicare, you can add a stand-alone Medicare Part D Prescription Drug Plan during this period as well. You also can switch Medicare Advantage plans during this period.
Timing your enrollment in a Medicare plan that offers prescription drug coverage is important. If you remain without creditable drug coverage (that is prescription drug coverage that is at least as comprehensive as Medicare Part D) for 63 days or more after your Initial Enrollment Period ends, you may have to pay a late-enrollment penalty for Medicare Part D, if you add this coverage later. In Massachusetts and the rest of the United States, this penalty is calculated using 1% of the national base beneficiary premium and the number of full months you were eligible for Medicare Part D but didn’t enroll. This amount is then added to your Medicare Part D monthly premium. The national base beneficiary premium may increase each year, which means your late-enrollment penalty may also increase annually.
In Massachusetts (and every state), each stand-alone Medicare Prescription Drug Plan and Medicare Advantage Prescription Drug plan has its own list of covered prescription drugs, called a formulary. The medications in the formulary may be grouped into different benefit categories called tiers, each with a different out-of-pocket cost to you. The lower tiers include the more affordable prescriptions drugs, while the higher tiers include more expensive medications. The formulary may change at any time. You will receive notice from your plan when necessary.
Most Medicare Part D prescription drug plans in Massachusetts (as in other states) let you choose between brand-name drugs and generic drugs. According to Medicare.gov, generic drugs are prescription drugs that have the same active-ingredient formula as brand-name drugs. The difference for you is that generic drugs usually cost less than the brand-name versions, resulting in lower out-of-pocket expenses.
Evaluating Medicare plans offering prescription drug coverage in Massachusetts
You may have several options available where you live in Massachusetts. As noted above, you may add a stand-alone Medicare Part D Prescription Drug Plan to your Original Medicare, Part A and/or Part B, coverage to help cover costs for prescription drugs. A Medicare Advantage Prescription Drug plan, on the other hand, combines health and prescription drug coverage into a single plan. Medicare Advantage plans include at least the same coverage as Medicare Part A and Part B (with the exception of hospice care which continues to be covered under Part A), and may offer extra benefits such as dental coverage or routine vision in a single plan. However, you must keep paying your monthly Medicare Part B premium.
When comparing Medicare plans offering prescription drug coverage in Massachusetts, it’s a good idea to make a list of your medications and check to see if they are on the drug formulary of any plan you’re considering. If you are currently enrolled in a Medicare plan offering prescription drug coverage, it’s wise to review your plan every year to keep up with any changes to your coverage. Your plan will send you an Annual Notice of Change and an Evidence of Coverage notice every fall.
Medicare plans providing prescription drug coverage in Massachusetts, like those in the rest of the United States, are allowed to change their premiums, copayments, deductibles, and drug formularies on an annual basis. Make sure you understand whether your current plan is best suited to your health and budget needs in the coming year or change, if possible, to one that can better serve your ongoing prescription drug coverage needs.
For more information about Medicare in Massachusetts, see the following pages: